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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT /j ��S 'k� <br /> lAILL ' n <br /> I C y j'er jV <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE / <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: �f�9� �;J S <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Print) T (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: gti' I/3(D <br /> (Mailing Address) <br /> f�,zcy L2� q.53 7Y <br /> �-(City)/ (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />